Step by step procedure to file a case against a health insurer

There may arise a situation in which a policyholder might feel unhappy with a health insurance company due to some settlement dispute, unfair practice, or negligence. Any conflict with a health insurance company can be resolved in multiple ways starting from filing a complaint with the insurer itself. If the resolution is not satisfactory, it can be escalated to the Insurance Regulatory and Development Authority of India (IRDAI). Further escalations over an unresolved issue can be directed to the Ombudsman or taken up in a Civil Court. The step by step mechanism in which a dispute is resolved can be detailed as follows.

Filing a complaint with the insurer

When a dispute occurs, it should be taken to the insurer first. The health insurance company will get in touch with the aggrieved customer over the issue. If there is an actual negligence or lapse on the company’s part, the company must be provided an opportunity to resolve the issue before it gets escalated to other channels.

All major health insurance companies in the country have their own mechanism for grievance redressal. The company’s customer service department can be contacted if there are any issues with the policy. If the issue is not resolved at the first point of contact, it can be escalated to the company’s grievance redressal office.

All major health insurance companies have a grievance redressal office that can be contacted for any major issues. Information about the contact details of this grievance redressal office can obtained in the official website of the insuresr. The following factors must be noted while filing a grievance dispute with a health insurer:

• Contact details of the insurer and the grievance redressal office can be taken from the policy document or the official website of the insurer.
• The complaint must be provided in writing along with all the associated documents.
• A written acknowledgement that contains the date of complaint can be obtained from the insurer after filing the complaint.
• Acknowledgement of a complaint will be done in a maximum of 3 days.
• Following acknowledgement, the grievance shall be resolved in a maximum of 15 days.
• If the issue is not resolved within 15 days, the customer can escalate it to the IRDA and file a complaint against the insurer.

Filing a complaint with the IRDA

The IRDA is the governing body for insurance service providers in the country. Companies that provide life and non-life insurance service for their customers must comply with the rules and regulations set forth by the IRDA. If an issue is not resolved by the company’s grievance redressal office, filing a complaint with the IRDA against the company is the next major step in the process. The contact details of IRDA can be given as follows:

Toll free phone number	155255 or 1800 4254 732
Email	complaints@irda.gov.in
Postal address	Insurance Regulatory and Development Authority of India(IRDAI) Consumer Affairs Department- Grievance Redressal Cell. Sy.No.115/1,Financial District, Nanakramguda, Gachibowli, Hyderabad-500032
Fax	040-66789768

Filing a complaint through IGMS

IRDA has a repository for collecting and monitoring insurance-related grievances in the form of Integrated Grievance Management System (IGMS). This system provides centralised access to all policyholders to air and monitor their grievances whenever there is an issue. This system also plays a key role in helping policyholders register their complaints if they are not able to access the insurance company directly. The process involved in registering a complaint with the IGMS can be listed as follows:

• Visit the IGMS portal through the website - http://igms.irda.gov.in/
• Register in the site by entering your valid credentials
• Log in to the portal and file a complaint or view its status

After the registration of a complaint, a reference number will be allocated to a policyholder. This reference number can be used to access the complaint in the future.

Things to note while filing a complaint with the IGMS:

• A complaint must be registered with the insurer first, and it must be escalated to the IRDA only if no action has been taken by the insurer.
• A complaint registered in the IGMS will flow through the insurer’s system as well as the IRDA repository.
• The complete access and control of the IGMS rests with the IRDA.
• The system comes with specific Turnaround Time (TAT) targets to measure the activities on complaints.

Grievance resolution through Ombudsman

The government of India came up with the Ombudsman scheme to settle the grievances of individual policyholders out of court in a cost-effective manner. The decision taken by the Ombudsman is binding on the insurer as well as the policyholder. Insurance Ombudsman offices are located in 17 cities in different parts of the country.

Complaints for which the Ombudsman can be approached:

• Complaints registered with the insurer that are either not satisfactorily resolved or lacked proper response
• Complaints on policies taken in one’s capacity as an individual
• Complaints on policies that have claim value (including expenses) below Rs.30 lakh

How to resolution process works:

• In case of a dispute, the Ombudsman will act as a mediator between the insurer and the policyholder and provide a recommendation for the dispute.
• If the parties involved are satisfied with the recommendation, the insurer will be directed to comply with the recommendation in a maximum of 15 days.
• If the recommendation is not satisfactory, the Ombudsman will pass an award in 3 months after considering all the aspects of the complaint.
• Once an award is passed, it is binding on the insurer and it must be implemented within a maximum of 30 days.

Filing a case in the consumer court

This action must be taken as the absolute last resort when all other dispute resolution mechanisms have failed to resolve the issue. A case can be filed against the health insurer in the consumer court. A lawyer must be involved to plead the case in the court of law. Consumer courts have separate departments to handle issues related to insurance grievances. Once the issue is taken to court, the judgment provided by the court is fully binding on the insurer as well as the policyholder.